Apr. 24, 2013

Dr. Nancy E. Epstein / Submitted

Written by

The Tennessean

Dr. Nancy E. Epstein, an editor at Surgical Neurology International, reviewed medical literature about steroid epidurals and concluded that “the multitude of risks attributed to these injections outweighs the benefits.”

Her editorial was published in a recent edition of the journal. Although she refers to the fungal meningitis outbreak, which was linked to tainted steroid medicine, her commentary focuses on other complications from epidurals that have received less attention, including scarring and allergic reactions.

Epstein, who has been a neurosurgeon for more than three decades, said she has treated many patients with complications from the pain treatment.

“People are coming in right, left and center, especially in the older population over 65, the geriatric group,” said Epstein, the chief of neurosurgical spine and education at Winthrop University Hospital in New York. “Each of them has had at least three epidural injections. I just saw a patient today who had six in the last year and six the year prior to that. A few months ago, I did (surgery on) some lady with lumbar spinal stenosis (narrowing of the spine) who had 12 in the course of a year. It’s ridiculous.”

Part of the problem, she contends, is that doctors who are not surgeons are administering the treatments. She said she has to fix the damage, including holes in the membrane that covers the spinal cord.

“There would be all these holes that these radiologists or pain management people or anesthesiologists had created,” Epstein said. “You would have to repair them because the size of the needle that they are using is usually fairly substantial. It makes a nice hole you have to repair. And it creates a lot of scarring in the epidural space.”

Dr. Christopher Standaert, the director of the health policy council for the North American Spine Society (NASS), said others reading the same reports Epstein cited could use numbers to come up with different conclusions. NASS represents members of medical professions that do epidurals, including anesthesiologists and radiologists.

Standaert, a professor at the University of Washington at Seattle who practices physical medicine and rehabilitation, said he administers steroid epidurals. Major complications from the procedures are uncommon, he said.

However, he agreed with Epstein that steroid epidurals do not provide long-term pain relief and noted that doctors do not promote the treatment as a permanent solution.

“There is no substantial evidence that epidural injections really provide long-term relief or change the long-term natural history of a problem,” Standaert said. “There are certainly issues with utilization and if they are all being utilized appropriately. Epidural injections certainly have a role. They remove inflammation. There’s data that they do provide short-term relief of pain. In certain patients, that’s beneficial.”

He pointed out that epidurals can be a much lower-risk procedure than spinal surgery, which can cause other serious complications.

“Epidurals don’t work for everything,” Standaert said. “They are much more effective for leg pain than back pain, for example. It’s really a minority of low back disorders that should even be considered for an epidural injection.”